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Health Links “Health Links will break down barriers for Ontarians, making access to health care easier and less complicated. By encouraging local health providers to work together to co-ordinate care for individual patients, we’re ensuring our most vulnerable patients – seniors and those with complex conditions – get the care they need and don’t fall between the cracks.” Deb Matthews, Minister of Health and Long-Term Care 3

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A New Model of Care in Ontario Health care providers in a geographic area work together to provide coordinated care for patients Patient-centred solutions Initially focused on people with the highest needs / highest cost to the health system Brings family health care into the broader health care system faster access to primary care faster ability to connect patients with specialists, home care services and other community supports improved transitions of care 4

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Health Link - Key Features Focus on a defined region (at least 50,000 population) Include providers that care for complex patients (minimum CCAC, hospital, primary care & specialists); voluntary participation Already show a high degree of collaboration and willing to formalize it with a written agreement Ability to identify and track complex patients Includes primary care providers (minimum 65% from the geographic area) Identifies a lead organization. 5

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6 Short Term: Develop coordinated care plans for complex patients Increase number of complex patients with regular and timely access to a primary care provider Providers will work together at the clinical level to achieve:

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Providers will work together at the clinical level to achieve: (cont’d) Longer Term: Introduce same day/next day access to primary care Primary care follow-up within seven days of discharge from an acute care setting Reduce time from a primary care referral to specialist and home care Reduce unnecessary hospital admissions and re-admissions within 30 days of discharge Reduce avoidable Emergency Room visits for patients with conditions best treated elsewhere Reduce Alternate Level of Care days in hospital Enhance the patient experience. 7

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Vision: Healthy people and healthy communities supported by a quality, accessible health system Mission: Building a coordinated, integrated and accountable health system for people where and when they need it Values: Respect, Trust, Openness, Integrity, Accountability 9 Champlain LHIN Integrated Health Service Plan 2013-2016 for a Person-Centred Regional Health Care System

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How Champlain Health Link Areas were Defined Applying the criteria: Staff studied data for 34 smaller ‘starter’ areas and combined them into 10 based on: Adjacency Critical mass (population, people with high needs, primary care and other providers) Population characteristics (distribution & demographics) Which hospitals people tend to use Our understanding of local areas Alignment with census and Ottawa Neighbourhood Study boundaries. 11

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Some High-Needs Groups (Champlain residents 2011-12) 1)Had two+ acute care hospitalizations: 13,939 Had a readmission within 30 days: 8,961 2)Had a high cost acute care hospital stay: 8,145 3)Made 5+ emergency department visits: 16,305 Composite: met one or more criteria: 30,514 Met all three criteria: 1,117 12 People with High Needs come in many shapes and sizes. No single data definition can capture the complexity. People with High Needs come in many shapes and sizes. No single data definition can capture the complexity.

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Readiness Assessments need to include: Evidence it was completed as a collaboration of providers, with a patient- centred focus (minimum PC, CCAC & hospital, specialists) A lead organization has been agreed upon by the collaborating partners & clearly identified An understanding of the Francophone population and their needs & an explanation of the a capacity to meet the needs of Francophones A description of Aboriginal population and collaborating partners to meet needs For each criterion of the Readiness Assessment template, the rationale / explanation section is completed and clearly written 15

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Helpful Tips Keep the focus on patients with the highest complexity and health system use Try not to get hung up on the “lead” organization Prepare a concise & clear RA – answer each criterion 16 Ministry website www.Ontario.ca/LeadingHealthy Change LHIN website: www.champlainlhin.on.ca LHIN email: Ch.pclead@lhins.on.ca